1.ID: 9476932222
A nurse is assigned to care for four clients on the medical-surgical unit. Which
client should the nurse see first on the shift assessment?
A. A client admitted with pneumonia with a fever of 100° F (37.8°C)
and some diaphoresis
B.
C. A client with congestive heart failure with clear lung sounds on the
previous shift
D. A client with new-onset of shortness of breath (SOB) and a history
of pulmonary edema Correct
E. A client undergoing long-term corticosteroid therapy with mild
bruising on the anterior surfaces of the arms
Rationale: The client who should be seen first is the one with SOB and a history
of pulmonary edema. In light of such a history, SOB could indicate that fluid-
volume overload has once again developed. The client with a fever and who is
diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid
through the skin, but this client is not the priority.
Test-Taking Strategy: Use the process of elimination and focus on the subject of
the question, the client who should be seen first. Recall the rule of assessment
of the ABCs — airway, breathing, and circulation — which means that the client
experiencing SOB should take precedence over the other clients on the unit.
This client’s condition could progress to respiratory arrest if the client were not
assessed immediately on the basis of the signs and symptoms. Read each
option and think about the client in most critical condition and review the
disorders to determine which clients have the most critical needs. If you had
difficulty with this question, review the various disease processes presented in
this question.
Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and
trends (8th ed., p. 305). St. Louis: Elsevier.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological
IntegrityIntegrated Process: Nursing Process/Assessment
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Clinical Judgment
HESI Concepts: Clinical Decision Making/Clinical Judgment,
Collaboration/Managing Care
, Awarded 1.0 points out of 1.0 possible points.
2.ID: 9476924021
A client with gastroenteritis who has been vomiting and has diarrhea is admitted
to the hospital with a diagnosis of dehydration. For which clinical manifestations
that correlate with this fluid imbalance would the nurse assess the client?
Select all that apply.
A. Decreased pulse
B. Decreased urine output Correct
C. Increased blood pressure
D. Increased respiratory rate Correct
E. Decreased respiratory depth
Rationale: A client with dehydration has an increased depth and rate of
respirations. The diminished fluid volume is perceived by the body as a
decreased oxygen level (hypoxia), and increased respiration is an attempt to
maintain oxygen delivery. Other assessment findings in insufficient fluid volume
are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry
mucous membranes, concentrated urine with increased specific gravity,
increased hematocrit, and altered level of consciousness. Increased blood
pressure, decreased pulse, and increased urine output occur with fluid-volume
overload.
Test-Taking Strategy: Use the process of elimination and focus on the subject,
dehydration (deficient fluid volume). Think about the pathophysiology of
deficient fluid volume. Remember that the body will increase the respiratory rate
in an attempt to maintain the oxygen level. If you had difficulty with this
question, review the signs of insufficient fluid volume.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 291-292). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes
Giddens Concepts: Clinical Judgment,Fluid and Electrolyte Balance
HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and
Electrolytes
Awarded 2.0 points out of 2.0 possible points.
3.ID: 9476934084
A nurse is reviewing the medical records of the clients to whom she is assigned
, on the 7 am–7 pm shift. Which client will the nurse monitor most closely for
excessive fluid volume?
A. A 48-year-old client receiving diuretics to treat hypertension
B. A 35-year old client who is vomiting undigested food after eating
C. An 85-year-old client receiving intravenous (IV) therapy at a rate of
100 mL/hr Correct
D. A 65-year-old client with a nasogastric tube attached to low suction
following partial gastrectomy
Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the
greatest risk for excessive fluid volume because of the diminished
cardiovascular and renal function that occur with aging. Other causes of
excessive fluid volume include renal failure, heart failure, liver disorders,
excessive use of hypotonic IV fluids to replace isotonic losses, excessive
irrigation of body fluids, and excessive ingestion of table salt. A client who is
receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at
risk for deficient fluid volume.
Test-Taking Strategy: Read the question carefully, noting that it asks for the
client at risk for excessive fluid volume. Read each option and think about the
fluid imbalance that could occur in each situation; in the case of the incorrect
options, it is fluid-volume deficiency; the only option reflecting conditions that
could result in an excess is the correct option. If you had difficulty with this
question, review the causes of excessive fluid volume.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 291, 293). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes
Giddens Concepts: Care Coordination, Fluid and Electrolyte Balance
HESI Concepts: Collaboration/Managing Care, Fluid and Electrolytes
Awarded 1.0 points out of 1.0 possible points.
4.ID: 9476926416
A nurse is caring for a client who is being treated for congestive heart failure
and has been assigned a nursing diagnosis of excessive fluid volume. Which
assessment finding causes the nurse to determine that the client’s condition has
, improved?
A. Dyspnea
B. 1+ edema in the legs
C. Moist crackles in the lower lobes of the lungs
D. Weight loss of 4 lb (1.8 kg) in 24 hours
E. Correct
Rationale: One sign that excessive fluid volume is resolving is loss of body
weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb
(1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is
retaining fluid. Assessment findings associated with excessive fluid volume
include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased
blood pressure and bounding pulse, increased central venous pressure, weight
gain, edema, neck and hand vein distention, altered level of consciousness, and
decreased hematocrit. These symptoms must be reversed if the fluid-volume
excess is to be resolved.
Test-Taking Strategy: Use the process of elimination and focus on the subject, a
sign that the client’s condition is improving. The only such finding is decreasing
body weight. If you had difficulty with this question, review the assessment
findings noted in excessive fluid volume and the signs that the condition is
resolving.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 292-293). St. Louis: Mosby.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Fluid and Electrolytes
Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance
HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and
Electrolytes
Awarded 1.0 points out of 1.0 possible points.
5.ID: 9476930486
A nurse notes that a client has ST-segment depression on the
electrocardiogram (ECG) monitor. With which serum potassium reading does
the nurse associate this finding?
A. 3.1 mEq/L (3.1 mmol/L) Correct
A nurse is assigned to care for four clients on the medical-surgical unit. Which
client should the nurse see first on the shift assessment?
A. A client admitted with pneumonia with a fever of 100° F (37.8°C)
and some diaphoresis
B.
C. A client with congestive heart failure with clear lung sounds on the
previous shift
D. A client with new-onset of shortness of breath (SOB) and a history
of pulmonary edema Correct
E. A client undergoing long-term corticosteroid therapy with mild
bruising on the anterior surfaces of the arms
Rationale: The client who should be seen first is the one with SOB and a history
of pulmonary edema. In light of such a history, SOB could indicate that fluid-
volume overload has once again developed. The client with a fever and who is
diaphoretic is at risk for insufficient fluid volume as a result of loss of fluid
through the skin, but this client is not the priority.
Test-Taking Strategy: Use the process of elimination and focus on the subject of
the question, the client who should be seen first. Recall the rule of assessment
of the ABCs — airway, breathing, and circulation — which means that the client
experiencing SOB should take precedence over the other clients on the unit.
This client’s condition could progress to respiratory arrest if the client were not
assessed immediately on the basis of the signs and symptoms. Read each
option and think about the client in most critical condition and review the
disorders to determine which clients have the most critical needs. If you had
difficulty with this question, review the various disease processes presented in
this question.
Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and
trends (8th ed., p. 305). St. Louis: Elsevier.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological
IntegrityIntegrated Process: Nursing Process/Assessment
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Clinical Judgment
HESI Concepts: Clinical Decision Making/Clinical Judgment,
Collaboration/Managing Care
, Awarded 1.0 points out of 1.0 possible points.
2.ID: 9476924021
A client with gastroenteritis who has been vomiting and has diarrhea is admitted
to the hospital with a diagnosis of dehydration. For which clinical manifestations
that correlate with this fluid imbalance would the nurse assess the client?
Select all that apply.
A. Decreased pulse
B. Decreased urine output Correct
C. Increased blood pressure
D. Increased respiratory rate Correct
E. Decreased respiratory depth
Rationale: A client with dehydration has an increased depth and rate of
respirations. The diminished fluid volume is perceived by the body as a
decreased oxygen level (hypoxia), and increased respiration is an attempt to
maintain oxygen delivery. Other assessment findings in insufficient fluid volume
are decreased urine volume, increased pulse, weight loss, poor skin turgor, dry
mucous membranes, concentrated urine with increased specific gravity,
increased hematocrit, and altered level of consciousness. Increased blood
pressure, decreased pulse, and increased urine output occur with fluid-volume
overload.
Test-Taking Strategy: Use the process of elimination and focus on the subject,
dehydration (deficient fluid volume). Think about the pathophysiology of
deficient fluid volume. Remember that the body will increase the respiratory rate
in an attempt to maintain the oxygen level. If you had difficulty with this
question, review the signs of insufficient fluid volume.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 291-292). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes
Giddens Concepts: Clinical Judgment,Fluid and Electrolyte Balance
HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and
Electrolytes
Awarded 2.0 points out of 2.0 possible points.
3.ID: 9476934084
A nurse is reviewing the medical records of the clients to whom she is assigned
, on the 7 am–7 pm shift. Which client will the nurse monitor most closely for
excessive fluid volume?
A. A 48-year-old client receiving diuretics to treat hypertension
B. A 35-year old client who is vomiting undigested food after eating
C. An 85-year-old client receiving intravenous (IV) therapy at a rate of
100 mL/hr Correct
D. A 65-year-old client with a nasogastric tube attached to low suction
following partial gastrectomy
Rationale: The older adult client receiving IV therapy at 100 mL/hr is at the
greatest risk for excessive fluid volume because of the diminished
cardiovascular and renal function that occur with aging. Other causes of
excessive fluid volume include renal failure, heart failure, liver disorders,
excessive use of hypotonic IV fluids to replace isotonic losses, excessive
irrigation of body fluids, and excessive ingestion of table salt. A client who is
receiving diuretics, vomiting, or has a nasogastric tube attached to suction is at
risk for deficient fluid volume.
Test-Taking Strategy: Read the question carefully, noting that it asks for the
client at risk for excessive fluid volume. Read each option and think about the
fluid imbalance that could occur in each situation; in the case of the incorrect
options, it is fluid-volume deficiency; the only option reflecting conditions that
could result in an excess is the correct option. If you had difficulty with this
question, review the causes of excessive fluid volume.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 291, 293). St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fluid and Electrolytes
Giddens Concepts: Care Coordination, Fluid and Electrolyte Balance
HESI Concepts: Collaboration/Managing Care, Fluid and Electrolytes
Awarded 1.0 points out of 1.0 possible points.
4.ID: 9476926416
A nurse is caring for a client who is being treated for congestive heart failure
and has been assigned a nursing diagnosis of excessive fluid volume. Which
assessment finding causes the nurse to determine that the client’s condition has
, improved?
A. Dyspnea
B. 1+ edema in the legs
C. Moist crackles in the lower lobes of the lungs
D. Weight loss of 4 lb (1.8 kg) in 24 hours
E. Correct
Rationale: One sign that excessive fluid volume is resolving is loss of body
weight. It is important to recall that 1 L of fluid weighs 1 kg, which equals 2.2 lb
(1 liter = 2.2 lb = 1 kg). The other options listed indicate that the client is
retaining fluid. Assessment findings associated with excessive fluid volume
include cough, dyspnea, rales or crackles, tachypnea, tachycardia, increased
blood pressure and bounding pulse, increased central venous pressure, weight
gain, edema, neck and hand vein distention, altered level of consciousness, and
decreased hematocrit. These symptoms must be reversed if the fluid-volume
excess is to be resolved.
Test-Taking Strategy: Use the process of elimination and focus on the subject, a
sign that the client’s condition is improving. The only such finding is decreasing
body weight. If you had difficulty with this question, review the assessment
findings noted in excessive fluid volume and the signs that the condition is
resolving.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 292-293). St. Louis: Mosby.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Fluid and Electrolytes
Giddens Concepts: Clinical Judgment, Fluid and Electrolyte Balance
HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and
Electrolytes
Awarded 1.0 points out of 1.0 possible points.
5.ID: 9476930486
A nurse notes that a client has ST-segment depression on the
electrocardiogram (ECG) monitor. With which serum potassium reading does
the nurse associate this finding?
A. 3.1 mEq/L (3.1 mmol/L) Correct
